The risk of fatal bleeding complications in jugular catheterization in patients with coagulopathy: A retrospective analysis of death cases in closed claims and the Medical Accident Investigating System in Japan.
The risk of fatal bleeding complications in jugular catheterization in patients with coagulopathy: A retrospective analysis of death cases in closed claims and the Medical Accident Investigating System in Japan.
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DOI：
10.1371/journal.pone.0261636
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发表时间：
2022
期刊：
影响因子：
3.7
通讯作者：
Kawachi S
中科院分区：
文献类型：
--
作者：
Otaki Y;Fujishiro N;Oyama Y;Hata N;Kato D;Kawachi S
为了防止再次发生医疗事故，日本医疗安全研究组织(MedSafe Japan)于2015年10月实施了医疗事故调查制度，以针对行政长官未能预见的医疗死亡。MedSafe Japan分析了该系统报告的10例与中心静脉置管相关的死亡病例，并于2017年3月发表了建议。然而，预防中心静脉插管相关死亡的重点尚不清楚。本研究旨在确定预防中心静脉插管相关死亡复发应强调的建议要点。我们评估了2002年1月至2016年12月期间医疗保险公司Sompo-Japan承保的8530例闭合索赔病例中的中心静脉置管。此外，我们比较了闭合索赔病例中与中心静脉插管相关的死亡病例与报告病例中的死亡病例。对37例闭合索赔病例的背景、错误类型、解剖插入位置和致死并发症数据进行了评估，其中12例(32.4%)为死亡病例。在12个封闭索赔案例和10个举报案例中，9个封闭索赔案例(75.0%)和9个举报案例(90.0%)与血管通路有关。其中，5例闭合索赔(41.7%)和7例报告(77.8%)与颈内静脉插管有关(p=0.28)。在5例闭合索赔病例中有3例(60.0%)观察到凝血障碍，在7例报告病例中有6例(85.7%)发生凝血障碍。凝血障碍患者行颈内静脉置管的风险必须仔细考虑。
To prevent recurrence of medical accidents, the Medical Accident Investigating System was implemented in October 2015 by the Japan Medical Safety Research Organization (Medsafe Japan) to target deaths from medical care that were unforeseen by the administrator. Medsafe Japan analyzed the 10 cases of central venous catheterization-related deaths reported in the system and published recommendations in March 2017. However, the particular emphasis for the prevention of central venous catheterization-related deaths is unclear. This study aimed to identify the recommendation points that should be emphasized to prevent recurrence of central venous catheterization-related deaths. We assessed central venous catheterization in 8530 closed-claim cases between January 2002 and December 2016 covered by the medical insurer Sompo-Japan. Moreover, we compared central venous catheterization-related death in closed-claim cases with death in reported cases. The background, error type, anatomic insertion site, and fatal complication data were evaluated for 37 closed-claim cases, of which 12 (32.4%) were death cases. Of the 12 closed-claim cases and 10 reported cases, 9 (75.0%) closed-claim cases and 9 (90.0%) reported cases were related to vascular access. Among these, 5 closed-claim cases (41.7%) and 7 reported cases (77.8%) were related to internal jugular vein catheterization (p = 0.28). Coagulopathy was observed in 3 (60.0%) of 5 closed-claim cases and 6 (85.7%) of 7 reported cases. The risk of internal jugular catheterization in patients with coagulopathy must be carefully considered.
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作者：
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